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עמוד בית
Sun, 14.07.24

August 2006

Original Articles
D. Tekes-Manova, E. Israeli, T. Shochat, M. Swartzon, S. Gordon, R. Heruti, I. Ashkenazi and D. Justo
 Background: Coronary heart disease is a major cause of morbidity and mortality worldwide. Early detection of cardiovascular risk factors and intervention may reduce consequential morbidity and mortality.

Objectives: To assess the prevalence of reversible and treatable cardiovascular risk factors among 26’477 healthy Israeli adults: 23’339 men and 3138 women aged 25-55 years.

Methods: We collected data during routine examinations performed as part of a screening program for Israel Defense Force personnel.

Results: The three most prevalent cardiovascular risk factors were a sedentary lifestyle (64%), dyslipidemia (55.1%) and smoking (26.8%). Overall, 52.9% of the men and 48.4% of the women had two or more cardiovascular risk factors. Moreover, 52.4% of young adult men and 43.3% of young adult women, age 25-34 years, had two or more reversible cardiovascular risk factors.

Conclusions: In this expectedly healthy population there was a high prevalence of reversible and treatable cardiovascular risk factors in both genders and in young age. These observations stress the need for routine health examinations and lifestyle modification programs even in the young healthy Israeli population.

H. Dar, C. Zuck, S. Friedman, R. Merkshamer and R. Gonen
 Background: The decision to undergo prenatal testing is influenced by ethnic or religious factors.

Objectives: To evaluate factors that might influence the decision of pregnant women to choose chorionic villous sampling for prenatal testing.

Methods: The study group comprised 239 women referred for prenatal diagnosis who elected to undergo CVS[1]. The data were analyzed according to indication, ethnic group and religion.

Results: Among women undergoing CVS because of advanced maternal age and because of anxiety, we noted a significantly high proportion of unbalanced families, i.e., with three or more children of the same gender and deviated gender ratio. We found a significant excess of males among the Jewish families and a significant excess of females among the non-Jewish families. Jews were over-represented in the monogenic group while Christian Arabs were over-represented in the maternal age/anxiety group.

Conclusions: The proportion of women who chose CVS for prenatal diagnosis varied according to indication, ethnic group and religion. The data in this study indicate that CVS may have been utilized for balancing families with ≥ 3 or more children of the same sex. Christian Arabs chose CVS more often than the other groups. Jewish women may have utilized CVS for family balancing of both sexes, while non-Jews may have utilized CVS for balancing families with ≥ 3 daughters. 


[1] CVS = chorionic villous sampling

A. Hamdan, R. Kornowski, A. Solodky, S. Fuchs, A. Battler and A.R. Assali

Background: The degree of left ventricular dysfunction determines the prognostic outcome of patients with acute myocardial infarction.

Objectives: To define the clinical, angiographic and procedural variables related to LV[1][1] dysfunction in patients with  with anterior wall AMI[1][2] referred for primary percutaneous coronary intervention.

Methods: The sample included 168 patients treated by primary PCI[1][3] for first anterior wall AMI. Clinical, demographic and medical data were collected prospectively into a computerized registry, and clinical outcome (death, reinfarction, major cardiovascular event) were evaluated during hospitalization and 30 days after discharge. Patients were divided into three groups by degree of LV dysfunction (mild, moderate, severe) and compared for clinical, angiographic and procedural variables.

Results: LV dysfunction was associated with pre-PCI renal failure (serum creatinine > 1.4 mg/dl), peripheral vascular disease, high peak creatine kinase level, longer door to balloon time, low TIMI flow grade before and after PCI, and use of an intraaortic balloon pump. On multivariate analysis adjusted for baseline differences, peak creatine kinase level (r = 0.3, P = 0.0001) and door to needle time (r = 0.2, P = 0.008) were the most significant independent predictors of moderate or severe LV dysfunction after anterior AMI.

Conclusion: Abnormal LV function after first anterior AMI can be predicted by door to balloon time and the size of the infarction as assessed by creatine kinase levels. Major efforts should be made to decrease the time to myocardial reperfusion.

[1][1] LV = left ventricular

[2] AMI = acute myocardial infarction

[3] PCI = percutaneous coronary intervention 

A. Primov-Fever, Y.P. Talmi, A. Yellin and M. Wolf
 Background: Intubation and tracheostomy are the most common causes of benign acquired airway stenosis. Management varies according to different conceptions and techniques.

Objectives: To review our experience with cricotracheal resection and to assess related pitfalls and complications.

Methods: We examined the records of all patients who underwent CTR[1] in a tertiary referral medical center during the period January 1995 to April 2005.

Results: The study included 61 patients (16 women and 45 men) aged 15–81 years. In 17 patients previous interventions had failed, mostly dilatation and T-tube insertion. Complete obstruction was noted in 19 patients and stenosis > 70% in 26. Concomitant lesions included impaired vocal cord mobility (n=8) and tracheo-esophageal fistula (n=5). Cricotracheal anastomosis was performed in 42 patients, thyrotracheal in 12 and tracheotracheal in 7. A staged procedure was planned for quadriplegic patients and for three others with bilateral impaired vocal cord mobility. Restenosis occurred in six patients who were immediately revised with T-tube stenting. Decanulation was eventually achieved in 57 patients (93.4%). Complications occurred in 25 patients, the most common being subcutaneous emphysema (n=5). One patient died of acute myocardial infarction on the 14th postoperative day.

Conclusions: CTR is a relatively safe procedure with a high success rate in primary and revised procedures. A staged procedure should be planned in specific situations, namely, quadriplegics and patients with bilateral impaired vocal cord mobility. 


[1] CTR = cricotracheal resection

L. Kaplan, Y. Bronstein, Y. Barzilay, A. Hasharoni and J. Finkelstein
 Background: Cervical spondylotic myelopathy is often progressive and leads to motor and sensory impairments in the arms and legs. Canal expansive laminoplasty was initially described in Japan as an alternative to the traditional laminectomy approach. The results of this approach have not previously been described in the Israeli population.

Objectives: To describe the technique of CEL[1] and present our clinical results in the management of patients with CSM[2] due to multilevel compressive disease.

Methods: All patients undergoing CEL during the period 1984–2000 were identified. Of these, 24 of 25 patients had complete clinical information. Mean follow-up was 18 months (range 4–48). Mean age was 60 years (range 45–72). One patient underwent CEL at three levels, 22 at four to five levels and 1 patient at six levels The primary outcome measure was improvement in spinal cord function (according to the Nurick classification).

Results: Twenty-three (96%) of the patients experienced relief of their symptoms. Of these, 11 patients showed improvement in their Nurick grade, 12 patients were unchanged and one had worsening. Intraoperative complications (epidural bleeding and dural tear) occurred in six patients. Two patients developed a late kyphosis.

Conclusions: Our treatment of choice for multilevel CSM is canal expansive laminoplasty as initially described by Hirabayashi. It provides the ability for posterior surgical decompression without compromising the mechanical stability of the spine. This approach has the benefit of not requiring internal fixation and fusion. Our clinical outcome and surgical complication rate is comparable to other studies in the literature.


[1] CEL = canal expansive laminoplasty

[2] CSM = cervical spondylotic myelopathy

E. Leibovitz, Y. Gerber, M. Maislos, E. Wolfovitz, T. Chajek-Shaul, E. Leitersdorf, U. Goldbourt and D. Harats for the HOLEM study group
 Background: Obesity is an independent risk factor for ischemic heart disease and affects the status of other risk factors for cardiovascular disease.

Objective: To study the attitude of physicians to obesity by examining discharge letters of overweight patients with ischemic heart disease.

Methods: We used the HOLEM database for this analysis. The HOLEM project was designed to study the NCEP (National Cholesterol Education Program) guideline implementation among patients with IHD[1] at hospital discharge. We documented the recording of risk factors and treatment recommendations for IHD by reviewing the discharge letters of 2994 IHD patients admitted to four central hospitals in Israel between 1998 and 2000. A follow-up visit was held 6–8 weeks after discharge, at which time the diagnosis of IHD was verified, risk factor status was checked, height and weight were measured and drug treatment was reviewed.

Results: Mean body mass index was 28.3 kg/m2 and 32% were obese (BMI[2] ³ 30 kg/m2). Only 39.6% of the obese patients and 65.8% of the morbidly obese patients (BMI ³ 40 kg/m2) had "obesity" noted in their discharging letters, and weight loss recommendation was written in only 15% of the obese patients' discharge letters. Acute episodes like acute myocardial infarction and unstable angina did not influence the notation of obesity, and only BMI and the number of additional risk factors were positively correlated with the notation of this risk factor.

Conclusions: Despite the importance of obesity, weight status was not noted and weight loss was not recommended in most of the discharge letters of obese IHD patients.


[1] IHD = ischemic heart disease

[2] BMI = body mass index

D.A. Vardy, T. Freud, P. Shvartzman, M. Sherf, O. Spilberg, D. Goldfarb and S. Mor-Yosef
 Background: Full medical coverage may often result in overuse. Cost-sharing and the introduction of a co-payment have been shown to cause a reduction in the use of medical services.

Objectives: To assess the effects of the recently introduced co-payment for consultant specialist services on patients' utilization of these services in southern Israel.

Methods: Computerized utilization data on specialists' services for 6 months before and 6 months after initiation of co-payment were retrieved from the database of Israel's largest health management organization.

Results: A decrease of 4.5% was found in the total number of visits to Soroka Medical Center outpatient clinics and of 6.8% to community-based consultants. An increase of 20.1% was noted in the number of non-actualized visits at the outpatient clinics. A decrease of 6.2% in new visits was found in the hospital outpatient clinics and of 6.5% in community clinics. A logistic regression model showed that the residents of development towns and people aged 75+ and 12–34 were more likely not to keep a prescheduled appointment.

Conclusion: After introduction of a modest co-payment, a decrease in the total number of visits to specialists with an increase in "no-shows" was observed. The logistic regression model suggests that people of lower socioeconomic status are more likely not to keep a prescheduled appointment.

Z. Kaufman, G. Aharonowitz, R. Dichtiar and M.S. Green
Background: Early clinical signs of influenza caused by a pandemic strain will presumably not differ significantly from those caused by other respiratory viruses. Similarly, early signs of diseases that may result from bioterrorism are frequently non-specific and resemble those of influenza-like illness. Since the time window for effective intervention is narrow, treatment may need to be initiated prior to a definitive diagnosis. Consequently, planning of medications, manpower and facilities should also account for those who would be treated for an unrelated acute illness.

Objectives: To estimate usual patterns of acute illness in the community as a baseline for integration into pandemic influenza and bioterrorism preparedness plans.

Methods: Between 2000 and 2003 we conducted 13 telephone surveys to estimate the usual incidence and prevalence of symptoms of acute illness in the community.

Results: On average, 910 households were included in each of the surveys, representing about 3000 people. The compliance rates for full interviews ranged from 72.3% to 86.0%. In winter, on average, about 2% of the Israeli population (individuals) suffered each day from fever of ≥ 38ºC, and about 0.8% during the other months. The prevalence of cough was higher, 9.2% in winter and 3% during summer. Daily incidence of fever ranged from about 0.4% per day in winter to about 0.2% in the fall. The prevalence and incidence of both fever and cough were highest for infants followed by children aged 1–5 years.

Conclusions: These background morbidity estimates can be used for planning the overall treatment requirements, in addition to actual cases, resulting from pandemic influenza or a bioterrorist incident.

Stem Cell Research
I. Goldberg Cohen, G. Beck, A. Ziskind and J. Itskovitz-Eldor
 Embryonic stem cells, derived from the inner cell mass of embryos in the blastocyst stage, are cells capable of perpetual self-renewal and long-term propagation and hold the potential to differentiate to progeny of the three embryonic germ layers. Since their derivation approximately two decades ago, exploration of mouse ES cells made major advances in ES cell differentiation research and in the successful development and propagation of various cell types. The subsequent derivation of ES cells from human embryos allows detailed study of early developmental events practically unreachable in early human embryos, and the potential derivation of a variety of adult cell types differentiated from the ES cells holds immense therapeutic promise. Recently, the study of ES cell-derived teratomas identified the partial presence of human ES cell-derived premature vessels within the teratoma, and a preliminary protocol for the in vitro derivation of a vascular progenitor was developed based on the study with the mouse ES cells. Furthermore, genetic profiling identified a pattern of expression of various endothelial and vascular smooth muscle cell genes that provide additional Information on the degree of vascular development that ES cells undergo. Finally, the clinical application of ES cells in transplantation medicine is closer than ever following the affirmation that human ES cell-derived endothelial progenitors conferred increased neovascularization in transplanted engineered skeletal muscle. This review summarizes these recent advances in vascular development from human ES cells and their potential clinical applications.

Case Communications
Clinical Views
A. Bar-Gil Shitrit, C. Reinus, S. Zeides and D. Braverman
E. Reinstein and Y. Shoenfeld
Book Corner
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